Field of the Invention
The invention is directed to compounds designed for targeted delivery of a JAK inhibitor to the gastrointestinal tract. The invention is also directed to pharmaceutical compositions comprising such compounds, methods of using such compounds to treat gastrointestinal inflammatory diseases, and processes and intermediates useful for preparing such compounds.
State of the Art
Inflammatory bowel disease, which primarily includes ulcerative colitis and Crohn's disease, involves chronic inflammation of all or part of the gastrointestinal tract. Ulcerative colitis is characterized by inflammation and ulceration of the mucosal layer of the rectum and the large intestine while Crohn's disease largely involves the ileum but can occur anywhere along the intestinal tract. Common symptoms include diarrhea, bloody stools, and abdominal pain. The clinical course of ulcerative colitis is intermittent, marked by alternating periods of exacerbation and remission. Incidence seems to be greater in developed than in developing countries. An estimated 1.3 million people in major industrialized countries suffer from ulcerative colitis and the numbers are expected to increase along with population growth. Patients with ulcerative colitis are at an increased risk of developing colorectal cancer. (e.g., Danese et al. N Engl J Med, 2011, 365, 1713-1725). In addition, an estimated 1 million people in industrialized countries suffer from Crohn's disease.
Although there exists a variety of therapeutic options to promote and maintain remission of ulcerative colitis (UC) in patients, none is ideal. Sulfasalazine-related treatments are often effective in mild UC, but much less so in moderate to severe disease. Corticosteroids are often used to provide rapid induction of remission in patients with moderate to severe UC. However, chronic use of steroids to maintain remission is discouraged due to their association with longer term adverse effects (e.g., osteoporosis and fractures, infections, cataracts, slower wound healing and suppression of adrenal gland hormone production). Systemic immunosuppressants such as azathioprine, cyclosporine and methotrexate have a slow onset and modest efficacy in moderate to severe UC patients, but prolonged use can be problematic due to consequences of long-term systemic immunosuppression (e.g., increased risk of infections and lymphoma). Anti-TNFα antibodies (e.g., infliximab and adalimumab), while expensive and requiring subcutaneous or intravenous administration, are efficacious in approximately 60 to 70% of UC patients with moderate to severe disease. However, up to one third of patients fail to respond adequately, while another third of initial responders develop tolerance over a few weeks (Allez et al., J Crohn's Colitis, 2010, 4, 355-366; Rutgeerts et al., N Engl J Med, 2005, 353, 2462-2476). The most recently approved UC therapy, vedolizumab, an anti-α4β7 integrin antibody, is efficacious in moderate to severe UC patients although its parenteral route is suboptimal, and the consequences of long-term immunosuppression via this mechanism remain to be determined. Despite existing therapeutic options, about 10 to 20% of UC patients still require colectomy within 10 years of diagnosis (Targownik et al., Am J Gastroenterol, 2012, 107, 1228-1235). It is clear there remains an unmet medical need for an effective therapy to promote and maintain remission of moderate to severe UC without the safety concerns resulting from chronic, systemic immunosuppression.
While the mechanism underlying ulcerative colitis is not completely understood, it is believed that environmental factors in genetically susceptible individuals evoke an inappropriate (excessive) reaction by the immune system to gut microbiota, resulting in colonic inflammation, tissue damage, and the associated symptoms characteristic of the disease.
Although the precise pathogenesis of UC is unclear, it is apparent that proinflammatory cytokines play a pivotal role in the immunological response (Strober et al., Gastroenterol, 2011, 140, 1756-1767). Many of the proinflammatory cytokines most commonly elevated in UC (e.g., IL-4, IL-6, IL-13, IL-15, IL-23, IL-24, IFNγ and leptin), rely on the JAK family of tyrosine kinases (i.e., JAK1, JAK2, JAK3 and Tyk2) for signal transduction. Ligand binding to a cytokine receptor triggers autophosphorylation of its associated JAK, which in turn results in phosphorylation of a signal transducer and activator of transduction (STAT) protein. Different STATs form hetero- or homodimers and promote transcription of their target genes in the cell nucleus to regulate functions such as cell growth, differentiation and death (Clark et al., J Med Chem, 2014, 57, 5023-5038).
Inhibition of the family of JAK enzymes could inhibit signaling of many key proinflammatory cytokines. Thus JAK inhibitors are likely to be useful in the treatment of ulcerative colitis and other inflammatory diseases such as Crohn's disease, allergic rhinitis, asthma, and chronic obstructive pulmonary disease (COPD). However, due to the modulating effect of the JAK/STAT pathway on the immune system, systemic exposure to JAK inhibitors may have an adverse systemic immunosuppresive effect.
Tofacitinib citrate (Xeljanz®), an oral, systemically available, pan-JAK inhibitor, was approved in the United States in November, 2012 to treat adults with moderately to severely active rheumatoid arthritis who have had an inadequate response to, or who are intolerant of, methotrexate. While demonstrating superior efficacy at higher doses in clinical studies, tofacitinib was only approved at a 5 mg twice daily (BID) dose based on dose-limiting, systemically-mediated, adverse events (e.g., elevated cholesterol, increased rate of opportunistic infections, neutropenia, lymphocytopenia, lymphoma and solid tumors). The drug carries a boxed warning in the US detailing the safety risks and was declined approval in Europe based on ‘significant and unresolved concerns’ about the overall safety profile. Tofacitinib is under active development for UC having demonstrated a clinical response in a Phase 2 (8 week) UC trial (Sandborn et al., N Engl J Med, 2011, 365, 1713-1725), particularly at the 10 mg and 15 mg BID dose (See also. Panes et al., BMC Gastroenterol, 2015, 15, 14), doses not currently approved for any indication. The sponsor has also reported a greater proportion of patients receiving tofacitinib 10 mg BID as compared to placebo were in remission in a Phase 3 (8 week) UC induction trial and also for patients receiving tofacitinib 5 mg and 10 mg BID in a Phase 3 (52 week) UC maintenance trial.
For the treatment of ulcerative colitis and other gastrointestinal inflammatory diseases, it would be desirable to provide a compound that on oral administration achieves sufficiently high exposure of tofacitinib in the gastrointestinal tract to optimize clinical efficacy while avoiding systemic dose-limiting systemic exposure.